Although a relatively rare occurrence, the unintended retention of foreign objects (URFO) after surgery not only harms the patient but adds significantly to the cost of medical care for a hospital, according to a report from the Joint Commission.

From 2005 to 2012, the Joint Commission has recorded 772 URFO incidents; 16 deaths related to these incidents have been recorded. The Pennsylvania Patient Safety Authority in 2009 estimated that the average total cost of care related to an URFO is about $166,000. This cost includes legal defense, indemnity payments, and surgical costs unreimbursed by CMS. (Since 2008, Medicare has refused to reimburse hospitals for care related to a foreign object retained after surgery.)

Root Causes

According to the Joint Commission, URFO incidents are usually the result of one or more of the following —

the absence of policies or procedures

failure to comply with existing policies and procedures

problems with hierarchy and intimidation

failure in communication with physicians

failure of staff to communicate relevant patient information

inadequate or incomplete education of staff

The most common risk factors for URFO incidents are patients with a high body mass index; an emergent or urgent procedure; or an unanticipated change during a procedure.

The traditional method of avoiding a URFO incident has been a manual counting protocol, but the Joint Commission notes that these procedures are prone to human error.

Prevention Suggestions

The Joint Commission recommends the following —

Create a highly reliable and standardized counting system to prevent URFOs.

Develop and implement effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.

Institute team briefings and debriefings as a standard part of the surgical procedure to allow the opportunity for any team member to express concerns they have regarding the safety of the patient, including the potential for an URFO.

Ensure that the surgeon verbally verifies the results of the counting procedure.

Document the results of counts of surgical items, instruments, or items intentionally left inside a patient and actions taken if count discrepancies occur.

Research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.